A nurse notices that a patient has an irregular pulse. The nurse should do which of the following?
a. Count the number of "lub-dubs" occurring in 30 seconds.
b. Assess how often the dysrhythmia is oc-curring.
c. Assess the radial pulse for a pulse deficit.
d. Chart the abnormally low heart rate as ta-chycardia.
B
A regular interval interrupted by an early beat, late beat, or a missed beat indicates an abnormal rhythm or dysrhythmia. A dysrhythmia alters cardiac function, particularly if it occurs repeti-tively. If your patient has a dysrhythmia you need to assess how often it is occurring. After prop-erly positioning the bell or the diaphragm of the stethoscope on the chest, try to identify the first and second heart sounds (S1 and S2). At normal slow rates, S1 is low pitched and dull, sounding like a "lub." S2 is a higher pitched and shorter sound and creates the sound "dub." Count the number of "lub-dubs" occurring in 1 minute. An inefficient contraction of the heart that fails to transmit a pulse wave to the peripheral pulse site creates a pulse deficit. To assess a pulse deficit, ask another nurse to assess the radial pulse rate while you assess the apical rate. Tachycardia is an abnormally elevated heart rate, more than 100 beats per minute in adults. Bradycardia is a slow rate, less than 60 beats per minute in adults.
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